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Complexities of Perioperative Pain Management in Orthopedic Trauma

  • Other Pain (A Kaye and N Vadivelu, Section Editors)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period.

Recent Findings

Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling.

Summary

The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an “underground” prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Massey GM, Dodds HN, Roberts CS, Servoss TJ, Blondell RD. Toxicology screening in orthopedic trauma patients predicting duration of prescription opioid use. J Addict Dis. 2005;24(4):31–41.

    Article  PubMed  Google Scholar 

  2. Morris BJ, Laughlin MS, Elkousy HA, Gartsman GM, Edwards TB. Preoperative opioid use and outcomes after reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(1):11–6. https://doi.org/10.1016/j.jse.2014.05.002.

  3. Macintyre PE, Huxtable CA, Flint SL, Dobbin MD. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care. 2014;42(5):558–74.

    PubMed  CAS  Google Scholar 

  4. Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR. Characteristics of opioid prescriptions in 2009. JAMA. 2011;305(13):1299–301. https://doi.org/10.1001/jama.2011.401.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  5. Lindenhovius AL, Helmerhorst GT, Schnellen AC, Vrahas M, Ring D, Kloen P. Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands. J Trauma. 2009;67(1):160–4. https://doi.org/10.1097/TA.0b013e31818c12ee.

    Article  PubMed  Google Scholar 

  6. Morris BJ, Mir HR. The opioid epidemic: impact on orthopaedic surgery. J Am Acad Orthop Surg. 2015;23(5):267–71. https://doi.org/10.5435/jaaos-d-14-00163.

    Article  PubMed  Google Scholar 

  7. Devin CJ, Lee DS, Armaghani SJ, Bible J, Shau DN, Martin PR, et al. Approach to pain management in chronic opioid users undergoing orthopaedic surgery. J Am Acad Orthop Surg. 2014;22(10):614–22. https://doi.org/10.5435/jaaos-22-10-614.

  8. Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011;93(21):1988–93. https://doi.org/10.2106/jbjs.j.01473.

    Article  PubMed  Google Scholar 

  9. Kidner CL, Mayer TG, Gatchel RJ. Higher opioid doses predict poorer functional outcome in patients with chronic disabling occupational musculoskeletal disorders. J Bone Joint Surg Am. 2009;91(4):919–27. https://doi.org/10.2106/jbjs.h.00286.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Helmerhorst GT, Vranceanu AM, Vrahas M, Smith M, Ring D. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014;96(6):495–9. https://doi.org/10.2106/jbjs.l.01406.

    Article  PubMed  Google Scholar 

  11. Chrastil J, Sampson C, Jones KB, Higgins TF. Postoperative opioid administration inhibits bone healing in an animal model. Clin Orthop Relat Res. 2013;471(12):4076–81. https://doi.org/10.1007/s11999-013-3232-z.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Holman JE, Stoddard GJ, Horwitz DS, Higgins TF. The effect of preoperative counseling on duration of postoperative opiate use in orthopaedic trauma surgery: a surgeon-based comparative cohort study. J Orthop Trauma. 2014;28(9):502–6. https://doi.org/10.1097/bot.0000000000000085.

    Article  PubMed  Google Scholar 

  13. Parran T Jr. Prescription drug abuse. A question of balance. Med Clin of North Am. 1997;81(4):967–78.

    Article  Google Scholar 

  14. Soderstrom CA, Smith GS, Dischinger PC, McDuff DR, Hebel JR, Gorelick DA, et al. Psychoactive substance use disorders among seriously injured trauma center patients. JAMA. 1997;277(22):1769–74.

  15. Levy RS, Hebert CK, Munn BG, Barrack RL. Drug and alcohol use in orthopedic trauma patients: a prospective study. J Orthop Trauma. 1996;10(1):21–7.

    Article  PubMed  CAS  Google Scholar 

  16. Carroll I, Barelka P, Wang CK, Wang BM, Gillespie MJ, McCue R, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115(3):694–702. https://doi.org/10.1213/ANE.0b013e31825c049f.

    Article  PubMed  Google Scholar 

  17. Stromer W, Michaeli K, Sandner-Kiesling A. Perioperative pain therapy in opioid abuse. Eur J Anaesthesiol. 2013;30(2):55–64. https://doi.org/10.1097/EJA.0b013e32835b822b.

    Article  PubMed  CAS  Google Scholar 

  18. Carroll IR, Hah JM, Barelka PL, Wang CK, Wang BM, Gillespie MJ, et al. Pain duration and resolution following surgery: an inception cohort study. Pain Med (Malden, Mass). 2015;16(12):2386–96. https://doi.org/10.1111/pme.12842.

    Article  Google Scholar 

  19. Singh JA, Lewallen DG. Predictors of pain medication use for arthroplasty pain after revision total knee arthroplasty. Rheumatology (Oxford, England). 2014;53(10):1752–8. https://doi.org/10.1093/rheumatology/ket443.

    Article  CAS  Google Scholar 

  20. Singh JA, Lewallen DG. Predictors of use of pain medications for persistent knee pain after primary total knee arthroplasty: a cohort study using an institutional joint registry. Arthritis Res Ther. 2012;14(6):R248. https://doi.org/10.1186/ar4091.

    Article  PubMed  PubMed Central  Google Scholar 

  21. • Berterame S, Erthal J, Thomas J, Fellner S, Vosse B, Clare P, et al. Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study. Lancet (London, England). 2016;387(10028):1644–56. https://doi.org/10.1016/s0140-6736(16)00161-6. Excellent review detailing use of and barriers to access to opioid analgesics.

    Article  Google Scholar 

  22. CDC. CDC grand rounds: prescription drug overdoses—a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10–3.

    Google Scholar 

  23. Rudd RA, Aleshire N, Zibbell JE, Matthew Gladden R. Increases in Drug and Opioid overdose deaths—United States, 2000-2014. Am J Transplant Off J Am Soc Transplant Am Soc Transplant Surg. 2016;16(4):1323–7. https://doi.org/10.1111/ajt.13776.

    Article  Google Scholar 

  24. Lee J. The pill hustle: risky pain management for a gunshot victim. Soc Sci Med (1982). 2013;99:162–8. https://doi.org/10.1016/j.socscimed.2013.08.032.

    Article  Google Scholar 

  25. Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part I—evidence assessment. Pain Phys. 2012;15(3 Suppl):S1–65.

  26. Grau LE, Dasgupta N, Harvey AP, Irwin K, Givens A, Kinzly ML, et al. Illicit use of opioids: is OxyContin a “gateway drug”? Am J Addict. 2007;16(3):166–73. https://doi.org/10.1080/10550490701375293.

  27. CDC. Today’s Heroin Epidemic. 2015. http://www.cdc.gov/vitalsigns/heroin/. Accessed July 14 2016.

  28. Franklin G, Sabel J, Jones CM, Mai J, Baumgartner C, Banta-Green CJ, et al. A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned. Am J Public Health. 2015;105(3):463–9. https://doi.org/10.2105/ajph.2014.302367.

  29. Howell D, Kaplan L. Statewide survey of healthcare professionals: management of patients with chronic noncancer pain. J Addict Nurs. 2015;26(2):86–92. https://doi.org/10.1097/jan.0000000000000075.

    Article  PubMed  Google Scholar 

  30. Benjamin DM. Prosecution of physicians for prescribing opioids to patients. Clin Pharmacol Ther. 2007;81(6):797–8. https://doi.org/10.1038/sj.clpt.6100115.

    Article  PubMed  CAS  Google Scholar 

  31. Nathan JI. Chronic pain treatment: a high moral imperative with offsetting personal risks for the physician—a medical student’s perspective. Pain Pract. 2009;9(2):155–63. https://doi.org/10.1111/j.1533-2500.2008.00257.x.

  32. Reidenberg MM, Willis O. Prosecution of physicians for prescribing opioids to patients. Clin Pharmacol Ther. 2007;81(6):903–6. https://doi.org/10.1038/sj.clpt.6100127.

    Article  PubMed  CAS  Google Scholar 

  33. Manasco AT, Griggs C, Leeds R, Langlois BK, Breaud AH, Mitchell PM, et al. Characteristics of state prescription drug monitoring programs: a state-by-state survey. Pharmacoepidemiol Drug Saf. 2016;25(7):847–51. https://doi.org/10.1002/pds.4003.

  34. • Wiznia DH, Zaki T, Maisano J, Kim CY, Halaszynski TM, Leslie MP. Influence of medical insurance under the affordable care act on access to pain management of the trauma patient. Reg Anesth Pain Med. 2017;42(1):39–44. https://doi.org/10.1097/AAP.0000000000000502. Recent study highlighting curtailed access to pain speecialists and barriers to care among Medicaid patients.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Foundation KF. Medicaid moving forward. 2014. http://kff.org/medicaid/fact-sheet/the-medicaid-program-at-a-glance-update/. Accessed July 9 2016.

  36. Wiznia DH, Averbukh L, Kim CY, Goel A, Leslie MP. Motorcycle helmets: the economic burden of an incomplete helmet law to medical care in the state of Connecticut. Conn Med. 2015;79(8):453–9.

    PubMed  Google Scholar 

  37. Hinman A, Bozic KJ. Impact of payer type on resource utilization, outcomes and access to care in total hip arthroplasty. J Arthroplast. 2008;23(6 Suppl 1):9–14. https://doi.org/10.1016/j.arth.2008.05.010.

    Article  Google Scholar 

  38. Manchikanti L. The growth of interventional pain management in the new millennium: a critical analysis of utilization in the medicare population. Pain physician. 2004;7(4):465–82.

    PubMed  Google Scholar 

  39. Manchikanti L, Hirsch JA. Obamacare 2012: prognosis unclear for interventional pain management. Pain Phys. 2012;15(5):E629–40.

    Google Scholar 

  40. Manchikanti L, Pampati V, Singh V, Boswell MV, Smith HS, Hirsch JA. Explosive growth of facet joint interventions in the Medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data. BMC Health Serv Res. 2010;10:84. https://doi.org/10.1186/1472-6963-10-84.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Manchikanti L, Pampati V, Singh V, Falco FJ. Assessment of the escalating growth of facet joint interventions in the medicare population in the United States from 2000 to 2011. Pain Phys. 2013;16(4):E365–78.

    Google Scholar 

  42. Manchikanti L, Singh V, Pampati V, Smith HS, Hirsch JA. Analysis of growth of interventional techniques in managing chronic pain in the Medicare population: a 10-year evaluation from 1997 to 2006. Pain Phys. 2009;12(1):9–34.

    Google Scholar 

  43. • Manchikanti L, Pampati V, Falco FJ, Hirsch JA. An updated assessment of utilization of interventional pain management techniques in the Medicare population: 2000-2013. Pain Phys. 2015;18(2):E115–27. Great reivew highlighting the growth of interventional techniques in pain management.

    Google Scholar 

  44. Zerzan JT, Morden NE, Soumerai S, Ross-Degnan D, Roughead E, Zhang F, et al. Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996 to 2002. Med Care. 2006;44(11):1005–10. https://doi.org/10.1097/01.mlr.0000228025.04535.25.

  45. Rasu RS, Vouthy K, Crowl AN, Stegeman AE, Fikru B, Bawa WA, et al. Cost of pain medication to treat adult patients with nonmalignant chronic pain in the United States. J Manage Care Specialty Pharm. 2014;20(9):921–8. https://doi.org/10.18553/jmcp.2014.20.9.921.

  46. Lalonde L, Choiniere M, Martin E, Levesque L, Hudon E, Belanger D, et al. Priority interventions to improve the management of chronic non-cancer pain in primary care: a participatory research of the ACCORD program. J Pain Res. 2015;8:203–15. https://doi.org/10.2147/jpr.s78177.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2—guidance. Pain Phys. 2012;15(3 Suppl):S67–116.

  48. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting. Anesthesiology. 2004;100(6):1573–81.

  49. Practice guidelines for acute pain management in the perioperative setting. A report by the American Society of Anesthesiologists Task Force on pain management, acute pain section. Anesthesiology 1995;82(4):1071–81.

  50. Peters CL, Shirley B, Erickson J. The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplast. 2006;21(6 Suppl 2):132–8. https://doi.org/10.1016/j.arth.2006.04.017.

    Article  Google Scholar 

  51. Franklin PD, Karbassi JA, Li W, Yang W, Ayers DC. Reduction in narcotic use after primary total knee arthroplasty and association with patient pain relief and satisfaction. J Arthroplast. 2010;25(6 Suppl):12–6. https://doi.org/10.1016/j.arth.2010.05.003.

    Article  Google Scholar 

  52. Oderda GM, Said Q, Evans RS, Stoddard GJ, Lloyd J, Jackson K, et al. Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother. 2007;41(3):400–6. https://doi.org/10.1345/aph.1H386.

  53. Wheeler M, Oderda GM, Ashburn MA, Lipman AG. Adverse events associated with postoperative opioid analgesia: a systematic review. J Pain. 2002;3(3):159–80.

    Article  PubMed  Google Scholar 

  54. Schug SA, Zech D, Grond S. Adverse effects of systemic opioid analgesics. Drug Saf. 1992;7(3):200–13.

    Article  PubMed  CAS  Google Scholar 

  55. Gan TJ, Lubarsky DA, Flood EM, Thanh T, Mauskopf J, Mayne T, et al. Patient preferences for acute pain treatment. Br J Anaesth. 2004;92(5):681–8. https://doi.org/10.1093/bja/aeh123.

  56. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77(5):1048–56.

    Article  PubMed  CAS  Google Scholar 

  57. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–41.

    Article  PubMed  Google Scholar 

  58. Joshi GP. Multimodal analgesia techniques for ambulatory surgery. Int Anesthesiol Clin. 2005;43(3):197–204.

    Article  PubMed  Google Scholar 

  59. White PF. Multimodal analgesia: its role in preventing postoperative pain. Curr Opin Investig Drugs. 2008;9(1):76–82.

    PubMed  CAS  Google Scholar 

  60. Elia N, Lysakowski C, Tramer MR. Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296–304.

    Article  PubMed  CAS  Google Scholar 

  61. Rathmell JP, Wu CL, Sinatra RS, Ballantyne JC, Ginsberg B, et al. Acute Post-Surgical Pain Management: A Critical Appraisal of Current Practice. Reg Anesth Pain Med. 2006;31(4):1–42. https://doi.org/10.1016/j.rapm.2006.05.002

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Authors and Affiliations

  1. Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA

    Daniel H. Wiznia, Theodore Zaki & Michael P. Leslie

  2. Yale Anesthesiology, Yale-New Haven Hospital, 20 York Street, New Haven, CT, 06510, USA

    Thomas M. Halaszynski

  3. Department of Adult and Perioperative Anesthesiology, Yale University School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA

    Thomas M. Halaszynski

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All authors have read the manuscript, agree that the work is ready for submission, and accept responsibility for the manuscript’s contents. Each author is a major contributor, analyzed the published literature, prepared and edited the manuscript, and approved the final version of the paper. In addition, all authors agree to be accountable for every aspect of the work, ensuring that questions related to its accuracy or integrity of any part of the work has been investigated and resolved.

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Correspondence to Thomas M. Halaszynski.

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Daniel H. Wiznia, Theodore Zaki, Michael P Leslie, and Thomas M. Halaszynski declare no conflict of interest.

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Wiznia, D.H., Zaki, T., Leslie, M.P. et al. Complexities of Perioperative Pain Management in Orthopedic Trauma. Curr Pain Headache Rep 22, 58 (2018). https://doi.org/10.1007/s11916-018-0713-5

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